This site is intended for health professionals only

At the heart of general practice since 1960

Developing an integrated musculoskeletal service

Ambitious plans to manage all rheumatology and non-trauma orthopaedic outpatient activity in primary care are being pioneered by GPs and a nurse consultant in Oldham, writes Dr Hugh Sturgess

Ambitious plans to manage all rheumatology and non-trauma orthopaedic outpatient activity in primary care are being pioneered by GPs and a nurse consultant in Oldham, writes Dr Hugh Sturgess

Pennine MSK Partnership is the first specialist provider medical services (SPMS) partnership of its kind developed to deliver a fully integrated, multidisciplinary, rheumatology, orthopaedic and chronic pain service. The philosophy is to deliver a one-stop service for patients closer to their home and a holistic approach to the management of musculoskeletal conditions.

We are also part of an 18-week referral-to-treatment pilot site, pioneering the development of pathways that minimise steps in the patient journey, including direct listing for surgery.

The initiative was born of a successful tier 2 rheumatology service commissioned and managed by Oldham PCT, but clinically led by GPSI Dr Alan Nye and nurse consultant Anne Browne. This service clinically triaged all rheumatology referrals and saw those patients where there was no clear evidence of an inflammatory arthritis.

The tier 2 service reduced referrals to secondary care by 70%, compared with the 30% reduction in the tier 2 orthopaedic service delivered by hospital-based physiotherapists.

A frustrating element of the tier 2 rheumatology service was the separation from our secondary care colleagues when there was doubt whether a patient should be referred. It was also frustrating for those patients who had inflammatory arthritis, to receive a quick assessment in our service but then face long waits for a secondary care appointment.

Practice-based commissioning is primarily concerned with the redesign of services to meet the needs of the local population. We first spotted the potential of developing an SPMS to further shift the care of patients closer to home within the Department of Health document Sustaining Innovation through New PMS Arrangements, published in March 2004.

Two local assessments of patient views, undertaken in 2004 and 2005, also showed a wish for more services to be moved out of the hospital setting.

Building our business case

We approached our PCT, which was supportive, and together formulated the concept of incorporating all rheumatology, non-trauma orthopaedic outpatient activity and chronic pain services into an SPMS.

Our PCT put the concept out to local tender. There were no other bidders as it was a unique design that no one else was really in a position to deliver.

Our business case was the development of a community-based multidisciplinary musculoskeletal service that would meet the needs of patients by transforming pathways of care. This would be achieved by breaking down professional demarcations through the development of the skills of allied health professionals (AHPs) engaged by the service.

The idea was fully supported by our consultant colleagues, who were willing to provide appropriate clinical governance support and clinics within the service.

We were awarded preferred bidder status in August 2005 and entered negotiations on the terms of a three-year rolling service level agreement (SLA), aiming for full integration of services in the third year. Funding for the service was a locally negotiated tariff saving 10-70% on the national tariff charged by the local hospital.

The SLA was signed off in January 2006 and the SPMS practice commenced business on 1 March 2006.

A multidisciplinary team

The service is clinically led by the three SPMS partners – Ms Browne, Dr Nye and myself, also a GPSI. The partners share the profits of the SPMS practice and, as is the case in general practice, this fosters innovation and efficiency.

We directly employ eight members of staff, six administrative and two clinical (a specialist nurse for osteoporosis and a specialist physiotherapist who manages the hand pathway) and we are about to appoint a business manager. All staff are entitled to be members of the NHS pension scheme.

We also engage specialist nurses, physiotherapists, podiatrists, occupational therapists and hospital consultants on SLA or private session arrangements.

The phased development of the service has been partly due to the need to negotiate release of clinical staff from the Royal Oldham Hospital. Negotiations with the management have been quite difficult at times. However, with the realisation that, as a primary care integrated clinical assessment and treatment service (ICAT), we are not in competition with them and we control the pathway of patients into scheduled inpatient care, they have come to accept that they need to work in partnership with us.

‘See and treat' policy

Patients are referred by their GP and the referral is clinically triaged using Choose and Book to enable electronic transfer of the referral. We now handle 280-450 referrals a month, which are appointed into 200 clinics each month. Our new to follow-up ratio averages 2.5:1. Five or six consultant rheumatology clinics are held a month; these are due to increase to four a week as we plan to transfer patients with inflammatory arthritis out of lifelong secondary care into our service over the next 12 months. Even with this increase, consultant sessions will account for less than 8% of the total clinics provided.

We try to operate a see-and-treat policy and discharge patients back to their GP after a single attendance where appropriate. We also offer patients the option of self-referral for injection therapy after their first attendance if they, and their GP, agree. This gives patients control over their treatment and minimises the steps to it. We also provide training for local GPs on joint assessment and injection techniques.

We have begun direct listing by AHPs for surgery of patients with carpal tunnel syndrome and trigger finger which have failed to respond to injection therapy. We are also working with our consultant colleagues to expand this to include certain foot procedures and, in time, total hip and knee replacements.

Shorter waiting times

The waiting time for first appointment in our service averages between two and four weeks. The percentage of patients seen within six weeks has stayed between 95% and 100% throughout the first year. This is despite incorporating the orthopaedic tier 2 service in October 2006, which managed twice as many referrals as the rheumatology tier 2 service. Since October 2006 there has been a 50% drop in new patient attendances in orthopaedic outpatients compared with the previous year. The waiting time for a new rheumatology outpatient appointment is about five weeks now, and once we shift all rheumatology into our service, we expect the wait to see a consultant to drop to between two and four weeks.

Feedback from referring GPs has been very positive on the whole and they are happy with the short waiting times and see- and-treat approach.

Oldham PCT is the only primary care site in the 18-week referral-to-treatment pilot programme and we are also a care closer to home demonstration site. Last year Pennine MSK won an innovation award from the British Society of Rheumatologists. Our service has been quoted as an example by the department, which sees integration of primary and secondary care as the future.

Looking to the future

Under the phased development of our scheme, we will be using capacity as it becomes available under the PCT's significant LIFT build programme.

This includes onsite radiology, minor theatre suite and space for an independent sector mobile MRI unit. This will enable us to transfer all outpatient activity and also deliver day case procedures.

Although aspects of setting up the service have been frustrating, the sense of being in control of its development has been a very positive experience. We have been visited by or have visited the department, health secretary Patricia Hewitt and Prime Minister Tony Blair. Dr Nye and I have had to reduce our commitment to our GP practice, which has not been greeted absolutely positively by our patients, but we have tried to keep them informed.

If GPs grasp the opportunity that PBC offers, then the world is our oyster. PCTs need to foster that innovation and we have been very lucky in that regard.

Dr Hugh Sturgess is a GP, GPSI and SPMS partner in Oldham, Lancashire; a GP affiliate to the Improvement Foundation and clinical chair of the foundation's North West centre; and chair of Oldham East Locality Commissioning Group

60 second summary

The initiatives

• SPMS partnership to deliver rheumatology, orthopaedic and chronic pain service

• Multidisciplinary team facilitating delivery of holistic care

• See-and-treat philosophy

• Direct listing to consultant's operating list

• 18-week referral-to-treatment pilot site and ‘care closer to home' demonstration site

Preparation time

20 months, including 12 months developing the concept

Staffing required

• Specialist nurses and physiotherapists, MSK podiatrists, hand occupational therapist and hospital consultants, on service level agreements or private session arrangements

• Direct employment of specialist nurse for osteoporosis and specialist physiotherapist who manages the hand pathway

• Six administrative staff

Start-up cost

£7,000 to support our time in developing the model


• Further 50% reduction in secondary care orthopaedic outpatient activity

• >95% patients seen within six weeks


• 10-70% reduction on national tariffs charged by our local trust

• Redesigning pathways and reducing patient's journey gives extra savings to PCT

• Partners draw profit shares from practice


Dr Hugh Sturgess, email

we try to operate a see-and-treat policy and discharge patients back to their GP after a single attendance

Rate this article 

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Have your say